COVID-19 and ENT Surgery.

In Otorhinolaryngology - Head and Neck Surgery, clinical examination and invasive procedures on the respiratory tract and on airway-connected cavities, such as paranasal sinuses and the middle ear, expose people to direct transmission of SARS-CoV-2 by inhalation or ocular projection of contaminated droplets, and to indirect transmission by contact with contaminated hands, objects or surfaces. Estimating an R0 of COVID-19 at around 3 justified postponing non-urgent face-to-face consultations and expanding the use of teleconsultation in order to limit the risks of SARS-CoV-2 infection of patients or health workers and comply with the lockdown. The health authority recommends cancellation of all medical or surgical activities, which are not urgent as long as this does not involve a loss of chance for the patient. The purpose of this cancellation is to significantly increase critical care capacity, prioritise the reception of patients with COVID-19, prioritise the allocation of staff and provision of the equipment necessary for their medical or surgical management, and contribute to the smooth running of downstream critical care within their establishment. Another goal is to reduce the risks of patient contamination within healthcare facilities. This document provides guidance on how to proceed with and adapt ENT surgery in the current pandemic context, as well as on the management of postponed operations. This best practice advice must of course be adapted in each region according to the development of the epidemic and pre-existing arrangements. Their local application can only be decided within the framework of collaboration between the ENT teams, the operational hygiene units and all the other specialties concerned.

[The place of the myocutaneous flap of the nasalis muscle in the repair of skin defects of the nasal pyramid]. / La place du lambeau myocutané du transverse du nez dans la réparation des pertes de substance de la pyramide nasale.

OBJECTIVES: analyze the importance of the myocutaneous flap of nasalis muscle of the nose in the reconstruction of skin defects of the nasal tip. This is a retrospective study concerning 15 patients treated from 2010 to december 2012 for basal cell carcinomas of the nasal tip. The minimum follow up was 6 months. We describe the procedure and the indications. The best site to be proposed for this flap is beyond question the latero-medial part of the nasal tip. It can be adapted to skin defects as large as 15 mm. Obviously since it is a skin island flap it is important to respect the pedicle between it and the nasalis muscle. The closure of the donor site is done in the alar-facial sulcus with a VY suture and scarring on this level is very negligible. We analyzed the aesthetic result which is often very good. One advantage of this flap is not to change the architecture of the nasal ala.

[Using the superficial temporal fascia flap in orbital surgery]. / Utilisation du lambeau de fascia temporalis superficialis en chirurgie orbitaire.

The superficial temporal fascia flap gives a fine malleable well vascularized tissue and can be used as a pedicled or a free flap to cover large areas of loss of substance. Its dissection needs a period of training. Its use in orbital surgery is rare. However when it is about an anophthalmic socket following radiotherapy with orbital retraction syndrome, it provides tissue of good quality. This could allow later reconstruction by mucous grafts. When used on cavities of exenteration it allows fast re-epithelialisation even post-radiotherapy, while allowing the monitoring of the cavity and in particular the early detection of any tumor recurrence. Its use is advantageous in unfavorable conditions especially after radiotherapy.

[Fronto-ethmoidal mucocele: a case report]. / Mucocèle fronto-ethmoidale: à propos d'un cas.

Paranasal sinus mucoceles can present ophthalmic disturbances. Our aim is to discuss the treatment and the endoscopic sinus surgery indication in the fronto-ethmoidal sinus mucoceles. We describe here a case of fronto-ethmoidal sinus mucocele in a patient with an important fronto-ethmoidal tumefaction and an increased prominence of his left eyeball. An endoscopic approach was done after explain to the patient the eventual risks and complications of the procedure, especially to his left eye.

[Analysis of the possibilities for reconstruction of partial nasal tissue loss]. / Choix des moyens de reconstruction des pertes de substances partielles de la pyramide nasale.

The surgical reconstruction of the nasal pyramid requires a precise analysis of the position, dimension and depth of the loss of substance. The means usable are numerous and the author gives his personal approach on the techniques which he generally carries out. In cancerology it is of course necessary to preliminarily perform a sufficiently broad excision before reconstruction. The plastic surgery must be done plane by plane with tissue of equivalent quality. Osseointegrated epistheses are to be reserved for particular cases when reconstructive plastic surgery cannot be proposed for local or general reasons.

[Autologous cartilaginous grafts in septorhinoplasties]. / Les greffons cartilagineux autologues dans les septorhinoplasties.

UNLABELLED: The use of cartilaginous graft is very common in septorhinoplasty. OBJECTIVES: This article analyses the ways of harvesting and implantation of the different type of cartilage: septal, auricular, tragal, alar and costal. It compares their advantages and disadvantages. The applications of cartilaginous grafts in primary and secondary septorhinoplasty are studied and illustrated by some clinical cases. CONCLUSION: the cartilage is the most reliable means of reconstruction that can be used in septorhinoplasty and it is, by far, the most used by the majority of authors. We don't use synthetic biomaterial in nasal surgery.

[Localized loss of facial tissue. Criteria of use of extra-oral implants and clinical cases]. / Pertes de substance faciale localisées. Critères de recours aux implants extra-oraux et cas cliniques.

Osseointegrated maxillofacial epitheses are an interesting therapeutic response for rehabilitation after loss of facial tissue when reconstructive plastic surgery cannot be proposed. We analyzed the criteria used for deciding on this type of treatment for the loss of local areas of auricular tissue, the nasal pyramid and the orbitopalpebral region, presenting individual clinical examples.

[Bone-anchored hearing aids BAHA: 10 years' experience]. / La prothèse auditive à ancrage osseux BAHA: 10 ans d'expérience.

Bone anchored hearing aid (BAHA), based on the concept of osseointegration, offers the possibility of restoring hearing in case of conduction or mixed deafness. We report our experience with 87 in 74 patients implanted from 1989 to 1999. The patients were divided into two major groups, with bilateral agenesia (22 cases) or chronic otitis media (52 cases). Anatomical results are very good. We got 3 extrusions with no osseointegration, 10% local infections and 3 traumas. Functional outcome was excellent, with 73 patients being fitted with 81 HC200, HC300 or HC360 prostheses. One patient had a functional failure. We stress the importance of rigorous audiometric criteria and the determinant factors of osseointegration, essentially the surgical technique. In patients with chronic otitis, BAHA offers a functional solution for those with no benefit from an air conduction hearing aid and who are not operable or decline a new operation for tympano-ossicular reconstruction. For cases of ear malformation, BAHA can be a temporary solution that does not damage the inner ear. Indeed, rehabilitation with a BAHA does not exclude the possibility of functional tympano-ossicular surgery when the child is older and if the anatomic conditions are favorable.

Anatomical results with titanium implants in the mastoid region.

We report our experience with titanium implants for extra-aural rehabilitation in the mastoid region with a bone-anchored hearing aid (BAHA) and auricular prosthesis. The purpose of this study was to evaluate the clinical status of the soft tissue adjacent to 63 skin-penetrating devices in 43 patients and to compare our findings with those of other reports. Forty-four fixtures have been implanted in 36 patients for the BAHA and 19 in seven patients for the auricular prostheses. The evaluation concerns osseointegration, pain in the mastoid area, skin reaction around the abutment and removal of the abutment. Three implants extruded; one due to trauma and two with no explanation. Follow-up ranged from 3 to 60 months after surgical implantation. The first outpatient check-up was performed at three months after implantation and then every six months. The soft tissue reaction around the percutaneous unit was classified at each control according to the classification proposed by Holgers et al. There was no irritation (type 0) in 87.5% of the controls for the BAHA group and in 87.2% for the group of auricular prostheses. No adverse skin reactions were noted in 61.36% of the BAHA group and in 66.66% of the auricular prosthesis group. Results of this study confirm the skin's ability to tolerate a skin-penetrating unit made of pure titanium. The importance of reducing the thickness of the skin around the implant and of local hygienic conditions is emphasized.

[Techniques of total reconstruction of the pinna]. / Les procédés de réhabilitation totale du pavillon auriculaire.

Reconstruction of the pinna must be adapted for each individual case. Surgical techniques which use autologous costal cartilage are the most reliable. During the 1970s Burt Brent described a technique in 4 stages which gives very good results. More recently, Satoru Nagata has proposed total reconstruction of the pinna in two stages. For cases where there is insufficient spare skin, a tissue expansion prosthesis may be used in cases with extensive scarring and fibrosis, the superficial temporalis fascia flap is useful. Bone-anchored prostheses are reserved for those cases in which surgery is contra-indicated for general reasons. Based on our experience of 119 reconstructions of the pinna, we discuss the various techniques which may be used.

[Decalcified, lyophilized, sterile heterotopic porcine ossicular xenografts. Experimental evaluation in the guinea pig]. / Les xéno-implants ossiculaires hétérotopiques porcins décalcifiés, lyophilisés et stérilisés. Evaluation expérimentale chez le cobaye.

Using the guinea pig middle ear model, we assessed decalcified, lyophylized, sterile heterotopic porcine ossicular xeno-implants based on a histology (optic and electron scan microscope) and immunologic (immunofluorscence) methods. Implants were placed in the middle ear and others in the dorsal subcutaneous area. Allo-implants were compared as controls. Implants were placed in the middle ear in 54 animals and skin implants in 14. Under the influence of BMP, the implant ossified in all cases in the middle ear. Intense immune recruitment was not observed. Inversely, there was a mononuclear infiltration reaction to the skin implants with formation of a fibrous capsule, immunoglobulin and complement influx and consequently sequestration. The allo-implants were partially reossified. These findings confirm the value of decalcification with hydrochloric acid for BMP induction, independent of species and the failure of attempted immune despecification. Implant outcome is not dependent on its antigen load, which is high compared with its weight, but on the site of implantation. The middle ear appears to be a privileged site of implantation.

[The use of osseointegration of hearing aids]. / Zastosowanie osteointegracji w protetyce sluchu.

The principles of osseointegration defined by Branemark are reviewed. The authors describe the otological applications of titanium implants: bone anchored hearing aids (BAHA). The good results obtained depend on the selection of the patients and the observance of a rigorous surgical technique. The present paper summarizes our results with 32 BAHA implanted in 27 patients.

[Leiomyosarcoma of the larynx: presentation of a case]. / Léiomyosarcome du larynx: présentation d'un cas.

The authors report a new case of laryngeal leiomyosarcoma. The patient was a 43-year-old-man. The tumor extended to the left vocal cord, the paraglottic space and the deep layers of the left false vocal cord. Histologically, the lesion showed the typical pattern of a grade-3 leiomyosarcoma. Immunochemical studies revealed a strong positive staining with the actin smooth muscle antisera. A partial laryngectomy was performed. There was no evidence of recurrent or metastatic disease 10 months after surgery.

[Maxillofacial prosthesis, fixation by endo-osseous implants and transcutaneous pillars]. / Epithèses maxillo-faciales, fixation par implants endo-osseux et piliers trans-cutanés.

Osseointegrated facial prostheses are an interesting solution in maxillo-facial rehabilitation when reconstructive plastic surgery is not envisageable. Authors report two cases and give their opinion on the use of this kind of prostheses.

[Current techniques of pharyngo-velar reconstruction after excision for cancer]. / Les techniques actuelles de reconstruction pharyngovélaire après exérèse carcinologique.

Carcinological surgery of the pharyngo-velar region poses delicate problems of reconstruction in exereses exceeding the midline. To avoid false alimentary pathways through the nose and phonatory problems (open rhinolalia), we propose the use, with or without the combination of a muscular cutaneous flap, of a free antecubital flap or of a latter is apparently fully satisfactory on the functional plane with the additional advantage of not leaving any aesthetic sequellae.

Anatomical and surgical particularities of cholesteatomas in children.

In children, cholesteatoma is closely related to dysfunction of the eustachian tube and evolves inside a malleable temporal bone. The importance of auditory and speech functions in such patients has caused us to use a very particular clinical philosophy. At the present time we have studied 154 cases of cholesteatomas in children under 15 years old. The following three points have been shown: the pathogenesis of a cholesteatoma can be of the primary type, secondary (due to an unfavorable extension of retraction pocket or to squamous cell migration) or even be iatrogenic; anatomical and clinical findings (with X-ray studies) predicate the treatment used; surgical treatment frequently requires a "second-look" operation.

Aesthetic surgery for microtia.

We describe here a technique for reconstruction of the external ear based upon an autogenous costal cartilage graft which is inserted into a cutaneous pocket dissected in the auricular area. Three subsequent procedures are then performed: rotation of the ear-lobe; reconstruction of the tragus; and elevation of the auricle. The ideal age for reconstruction is about 7 years. This technique was originally described by Brent, who has a very extensive experience with this kind of surgery. Skin deficiencies can be overcome by using either a temporo-parietal fascial flap or a skin expander.

[Mérocel's method in otorhinolaryngology]. / Apport du Mérocel en oto-rhino-laryngologie.

Merocel intra-nasal pack are very effective in controlling epistaxis. Different forms of Merocel are very usefull in external otitis and after endonasal and middle ear surgery. They can protect some particular structures during oto-neuro and head and neck surgery.

[Rhinoplasty using an external approach: experience in Bordeaux]. / La rhinoplastie par voie externe: expérience bordelaise.

Rhinoplasty using an external approach is an option of rhinoplastic surgeons; its use should be reserved for specific indications, essentially post-traumatic surgery or re-surgery after rhinoplasty.